Recurring concern

Unreliable use of Mental Health Act holding powers

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First reported 1 Aug 2016•Latest report 19 Dec 2022

Definition

What this concern includes

Includes failures in the operation of Mental Health Act holding powers under Sections 5(2) and 5(4), including understanding their significance and effect, completing valid paperwork, recognising when the powers are available, and using them when required for patient safety.

Not included

  • Excludes failures concerning other Mental Health Act powers or statutory processes, such as Sections 2, 4, 135 or 136, unless the assertion specifically concerns a Section 5(2) or 5(4) holding power.
  • Excludes generic mental-health training, staffing or communication deficiencies unless they directly impair the lawful operation or use of a Mental Health Act holding power.
  • Excludes detention or restriction without an identified failure of the Section 5(2) or 5(4) holding-power process.
  • Excludes clinical assessment, treatment or discharge failures where the Mental Health Act holding-power process is not the deficient control.
Reports
3

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2016–2022

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

All Interested Persons1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Health and Social Care Northern Ireland1
NHS England1
NHS Scotland1
Office of the Chief Coroner1
Royal College of Nursing1
Royal College of Psychiatrists1
Royal Free London NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East Riding and Hull

    AI-generated summary

    Mollie Rose Stansfield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power

    Wider context from the report

    “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given. ”

    Source location

    Mollie Rose Stansfield · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to properly complete Section 5(2) Mental Health Act paperwork

    Wider context from the report

    “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given. ”

    Source location

    Mollie Rose Stansfield · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Raise the Mental Health Order’s patient-detention powers with HSC Trust chief executives and relevant professional bodies.

    Verbatim wording from the response

    “Having considered the findings of the report, I agree with the importance of ensuring that Health and Social Care Trusts and relevant health practitioners here should be reminded of the powers under the Mental Health Order for the detention of patients. I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point.”

    Source location

    Response from Department of Health
    Page 1 · response
    Published 4 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Run a pilot enabling SAS doctors to gain Section 5(2) competence through the portfolio route.

    Verbatim wording from the response

    “In order to enable additional further capacity, HEE is also currently undertaking a pilot to allow Specialty and Associate Specialist (SAS) doctors to gain competence via the same portfolio route as non-medical staff. SAS doctors are employed in the NHS in a non-training post and will have at least seven years’ experience of working in psychiatry, four of which at a senior level.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 January 2023

    Open published response

  2. Southampton and New Forest

    AI-generated summary

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Erroneous belief that informal patients cannot be detained when safety concerns arise

    Wider context from the report

    “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

    Source location

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of ward nurses to use section 5(4) powers to prevent unsafe patient departure

    Wider context from the report

    “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

    Source location

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. London Greater (East)

    AI-generated summary

    Joshua Knox-Hooke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joshua Knox-Hooke, a 22-year-old man with psychosis and recent drug use, attended North Middlesex Hospital on 1 December 2014 after cutting his neck and wrist and saying he wanted to kill himself. He left before psychiatric assessment and was later found deceased, partly immersed in Danbury reservoir; the inquest concluded that he died from drowning. Concerns included failure to keep him within eyesight in accordance with hospital policy and wider issues around patients leaving before psychiatric assessment and the handling of the incident.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff awareness of nurses' holding power under Section 5.4 of the Mental Health Act

    Wider context from the report

    “3. The triage nurse who gave evidence during the course of the Inquest did not consider that it would be possible to make a patient to remain within the hospital for their own safety. She was unaware of the nurses holding power under Section 5.4 of the Mental Health Act. ”

    Source location

    Joshua Knox-Hooke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Explore whether a registered mental health nurse can be provided at short notice when high-risk patients cannot be assessed within the specified time.

    Verbatim wording from the response

    “The Trust is confident that the actions outlined above, specifically the introduction of the MHTF, will ensure high risk mental health patients are appropriately identified and assessed in a timely manner so as to reduce the risk of such patients absconding prior to assessment in future. However, the Trust has also explored whether Barnet, Enfield & Haringey Mental Health Trust are able to provide a registered mental health nurse, capable of exercising the holding powers afforded by section 5.4 of the mental health act, at short notice at times when it is not possible for a patient identified as being high risk of being appropriately assessed within the specified time. In instances where BEH MHT cannot provide sufficient RMN support to the ED, the ED attempts to book agency RMN staff at short notice.”

    Source location

    Knox-Hooke-Response
    Page 2 · response
    Published 1 August 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The hospital cannot exercise Mental Health Act holding powers because it does not provide mental health services or employ authorised registered mental health nurses.

    Verbatim wording from the response

    “The Trust notes that you explicitly identified the fact that the triage nurse caring for Mr Knox-Hooke in ED was unaware of the nurses holding power under section 5.4 of the Mental Health Act, as a matter of concern. The Trust also notes, however, that the holding power afforded by the Mental Health Act is only to be exercised by a registered mental health nurse who has had appropriate training. The Trust is not a provider of mental health services and this service is provided on site by Barnet, Enfield & Haringey Mental Health Trust. Therefore North Middlesex University Hospital NHS Trust does not employ registered mental health nurses with the authority to detain patients under section 5.4 of the mental health act.”

    Source location

    Knox-Hooke-Response
    Page 2 · response
    Published 1 August 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Mental health services and registered mental health nurse support are provided by Barnet, Enfield & Haringey Mental Health Trust.

    Verbatim wording from the response

    “In summary, Mr Knox-Hooke was able to leave the Emergency Department whilst he awaited psychiatric assessment at a time when he was not being observed. The Trust does not provide mental health services and these services are provided on site, in the Emergency Department, by Barnet, Enfield & Haringey Mental Health Trust. In order to reduce the risk of high risk mental health patients leaving the department before they are assessed, the Trust has implemented action to reduce the waiting time for assessment for these patients. The Trust has also implemented a Mental Health Triage Form (MHTF) and prioritisation tool, a copy of which is enclosed. This tool has improved the identification of mental health risk factors at triage and enables high risk patient to be systematically identified so that their mental health assessment is prioritised.”

    Source location

    Knox-Hooke-Response
    Page 1 · response
    Published 1 August 2016

    Open published response
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Data last updated 7 September 2026